J Rehabil Med 2014; 46: 754760

ORIGINAL REPORT

Effectiveness of integrated multidisciplinary rehabilitation

in primary brain cancer survivors in an Australian
community cohort: a controlled clinical trial

Fary Khan, MBBS, MD, FAFRM (RACP)1,2,3, Bhasker Amatya, MD, MPH1, Kate Drummond
MBBS, MD, FRACS3,4 and Mary Galea, PhD, BAppSci (Physio), BA, Grad Dip Physio, Grad
Dip Neurosci1,3
From the 1Department of Rehabilitation Medicine, Royal Melbourne Hospital, 2School of Public Health and Preventive
Medicine, Monash University, 3Department of Medicine (Royal Melbourne Hospital), The University of Melbourne and
4
Department of Neuroscience, Royal Melbourne Hospital, Parkville, Victoria, Australia

Objective: To evaluate effectiveness of a multidisciplinary INTRODUCTION

rehabilitation program for persons following definitive pri-
mary brain tumour treatment in a community cohort.
Methods: The brain tumour (glioma) survivors (n=106)
were allocated either to the treatment group (n=53) (in-
tensive ambulatory multidisciplinary rehabilitation), or the
waitlist control group (n=53). The primary outcome Func-
tional Independence Measure (FIM), measured Activity
limitation; secondary measures included Depression, Anxi-
ety Stress Scale, Perceived Impact Problem Profile and Can-
cer Rehabilitation Evaluation System. Assessments were at
baseline, 3 and 6 months after program completion.
Results: Participants were predominantly women (56%),
with mean age 51 years (standard deviation 13.6) and median
time since diagnosis of 2.1 years. Intention-to-treat analysis
showed a significant difference between groups at 3-month
in favour of multidisciplinary rehabilitation program in
FIM motor subscales: self-care, sphincter, locomo- medium to longer-term functional and psychosocial impair-
tion, mobility(p<0.01 for all); and FIM communication ments that limit daily activity and participation (6, 7).
(p<0.01) and psychosocial subscales (p<0.05), with small
to moderate effect size (r=0.20.4). At 6-month follow-up,
significant improvement in the treatment group was main-
tained only for FIM sphincter, communication and cog-
nition subscales (p<0.01 for all). No difference between
groups was noted in other subscales.
Conclusions: brain tumour survivors can improve function
with multidisciplinary rehabilitation, with some gains main-
tained up to 6 months. Evidence for specific interventions in
the blackbox of rehabilitation is needed.
Key words: brain tumour; rehabilitation; participation; quality
of life; function.
J Rehabil Med 2014; 46: 754760
Correspondence address: Prof Fary Khan MBBS, MD, FAFRM
(RACP), Director, Department of Rehabilitation Medicine,
Royal Melbourne Hospital, Poplar Road, Parkville, Melbourne
VIC 3052, Australia. E-mail: fary.khan@mh.org.au
Accepted Mar 31, 2014; Epub ahead of print Jun 4, 2014
Primary brain tumours (BT) account for 2% of all cancers
(1) and affect 7 per 100,000 population worldwide annually
(2). The overall incidence of BT has increased, especially in
patients over 60 years of age (3). In Australia, the estimated
number of new cases of BT are approximately 1,400 per an-
num; and over 1,200 deaths annually (4). BT can be a source of
disability and morbidity; associated with significant costs and
socioeconomic implications with increased demand for health
care, social and vocational services; and caregiver burden.
Current therapeutic advances in the treatment of BT have
resulted in improved survivorship (5, 6). The mainstay of
treatment is maximal safe surgical resection of the tumour fol-
lowed by radiation therapy and chemotherapy as indicated (3,
6). These treatment regimens can produce adverse effects (7).
Despite various treatment options, patients suffer significant
The International Classification of Functioning, Disability
and Health (ICF) (8) framework defines a common language
for describing the impact of disease at different levels. For
example, BT related impairments (headaches, seizures, neuro-
cognitive dysfunction, paresis, dysphasia), can limit activity
(decreased mobility, inability to self-care) and participation
(work, family, social reintegration), and reduce life span (9).
One study reported that a quarter of the adult survivors of child-
hood BTs experience visual and/or hearing deficits (23%), loss
of sensation (21%) (10) and significantly lower muscle strength
(grip, knee extension) and exercise tolerance compared with
their matched counterparts (10). These disabilities can have
a cumulative effect over time and cause considerable distress
to the cancer survivors and their families, and reduce quality
of life (QoL). Patients discharged back to the community
are confronted by various ongoing concerns (relationship,
employment, recurrence) in the medium to longer-term (11).
Families often struggle to cope with new demands associated
with increased care needs, inability to return to driving and

J Rehabil Med 46 2014 The Authors. doi: 10.2340/16501977-1840

Journal Compilation 2014 Foundation of Rehabilitation Information. ISSN 1650-1977
 Effectiveness of multidisciplinary rehabilitation in brain tumour
work, financial constraints, marital stress and general limitation
in patients participation.
BT is a complex and challenging condition requiring inte-
grated multidisciplinary care and services. The UK National
Service Framework for Long-Term Neurological conditions
(12) (including BT), advocates 11 Quality-Requirements
for integrated, life-long, person-centred care, and provides
guidelines to explore the interaction between neurology,
rehabilitation and palliative care services (neuropalliative-
rehabilitation), in hospital and community. Needs must be
defined so services can be matched for these individuals to
optimise care. However, no studies currently utilize this pro-
posed model of care in the BT population.
Although several studies evaluate functional outcomes for
BT survivors from a multidisciplinary rehabilitation (MDR)
perspective (7, 1321), many are methodologically flawed
(bias, lack of control group and blinding). A recent system-
atic review of MDR for BT (22) identified no randomized or
controlled clinical trial (RCT/CCT) in this area. However,
10 observational studies of poor methodological quality
provided weak evidence for short-term gains for impair-
ment, psychosocial adjustment and QoL. No studies explored
participation (social reintegration, return to driving, work) and
none were in the Australian context. To date no clinical trials
have evaluated effectiveness of MDR outcomes or comparisons
of different methods of treatment in these persons. Therefore,
the aim of this study was to evaluate the effectiveness of MDR
in persons after BT treatment in an Australian community
cohort. The effectiveness of rehabilitation in these survivors
was expected primarily in the activity domains and secondly
in participation.
METHODS
Participants and setting
This prospective CCT was part of rehabilitation research program for
BT survivors (gliomas), conducted at the Royal Melbourne Hospital
(RMH), a tertiary referral centre in Victoria, Australia. The RMH MDR
program provides intensive individualized treatment for BT survivors
both in ambulatory and inpatient settings.
The recruitment process has been reported previously (11, 23). A
clinical quality improvement audit at RMH identified 862 consecutive
admissions for acute care between 20072011, with the International
Classification Diseases (ICD) Code (C71) for BT (main diagnosis)
incorporating all 10 sub-codes (C71.071.9) (excludes cranial nerves).
These included same and multiday patients and those with recurrent
admissions (details available from authors). The RMH Database was
used for cross-indexing of diseases from HOMER using the Patient
Administrator System of the Hospital Information Systems. The
source of these patients was a pool of persons residing in the com-
munity, referred to the RMH from public and private medical clinics
across greater Melbourne in Victoria. All patients were aged 18 years
and over and fulfilled criteria for BT grading system (Grade IIV)
for gliomas as outlined by the WHO for Central Nervous System
Tumours (24); and assessed by a surgeon/oncologist. The inclusion
criteria for intensive MDR included: stable medical course, post BT
surgery, radiotherapy and/or chemotherapy, assessed by a rehabilita-
tion physician/neurosurgeon for presence of neurological deficits and
ability to participate in therapy up to 2.5 h of interrupted therapy/day;
and the clinical judgment of the assessing rehabilitation team. These
755
participants resided in the community (area of greater Melbourne <60
km radius), and were able to communicate in English. Those who
had benign or metastatic BTs, significant co-morbidities or medically
unstable, or psychiatric disorders (such as uncontrolled schizophrenia,
actively suicidal/self-harm or physically aggressive (based on clinical
judgement)) limiting participation in rehabilitation, those bed-bound
and/or institutionalized in nursing homes were excluded.
The study was approved by the Royal Melbourne Hospital Ethical
Committee (No. 2010.216) and informed consent was obtained from
all the subjects.
Procedure
Group allocation. All eligible patients (n=152) based on selection
criteria were contacted by mail and invited to participate in this
project by an independent project officer. A total of 106 subjects who
consented were recruited for the study (Fig. 1). Consistent with usual
care procedures, all patients were mailed an information package
(containing standard BT education, information and support services
details). After written informed consent, all participants were assessed
and baseline data was obtained in a subacute clinical settings. All
patients were allocated either to the treatment or control group by
the treating team based on their clinical need. Attempts were made to
ensure equal distribution of more aggressive BTs (based on histology)
in each group. The treatment group (n=53) received an individualized
intensive ambulatory (centre-based) MDR, while the waitlist patients
were the control group (n=53), who continued with their usual activ-
ity in the community (see details below), monitored by their surgeon/
oncologist and/or family doctors. The control group were informed
that it could take between 2 to 3 months before they received intensive
rehabilitation, consistent with current practice.
Assessment interviews. After group allocation all baseline assess-
ments and interviews were completed using a structured format, by
3 independent experienced trained researchers over a 6-week period.
These assessors (two physicians and a research officer) received a
3-day training session in cognitive and functional ability assess-
ments examined and accredited by a national body (the Australian
Rehabilitation Outcomes Centre). They were not in contact with the
acute surgical/oncological or the treating rehabilitation teams. They
did not share information about participants or assessments, and re-
ceived separate and different clinical record forms at each interview.
The information obtained included: demographic and disease-related
information, cognitive and functional ability assessment and health-
related QoL measures using standardized instruments (see measures).
These interviews took approximately 40 min, with appropriate rest
breaks. The assessors did not prompt participants, but provided as-
sistance for those who had difficulty completing the questionnaires.
All participants were evaluated at recruitment and at 3 and 6 months
after completion of their rehabilitation program by the same three
assessors. The assessors did not have access to previous assessments,
treatment schedules or treating rehabilitation therapy team documenta-
tion. Participants were instructed to make no comments on whatever
treatment they received in the time interval between examinations and
only to report any concurrent illness or hospitalization. The control
group was monitored in the community as per usual by their treating
general practitioners/oncologists/surgeons. All assessments were se-
cured and filed, and opened only at the time of entry into the database
by an independent data entry officer.
Treatment schedules
Participants in the treatment group received comprehensive indi-
vidualized MDR (for up to 68 weeks) over the study period. An
assessment of each patients potential to benefit from MDR program
was based on clinical features, individual need and accessibility to
services, and made by a treating therapy team, who were not aware
of the allocation of patients in the trial. They assessed these patients
along with the usual referrals from the community referred by general
J Rehabil Med 46
756 F. Khan et al.

practitioners, community health centres and other hospitals (general,
surgical and oncology units) for a range of disabilities, consistent
with current practice.
The MDR program included intensive treatment beyond symp-
tomatic management of BT, which was individualized, achievable,
time-based, functional, and goal-oriented with active involvement of
patient (and family). The MDR incorporated a wide range of elements,
such as education and health promotion for those mildly affected, to
intensive mobilization and task reacquisition programs for the more
severely affected patients. Consistent with existing practice at the
RMH, MDR comprised half-hour blocks of therapy sessions (Social,
Psychology, Occupational Therapy and Physiotherapy), 2 to 3 times
per week for up to 8 weeks. A priori compliance with treatment was
defined as participant attendance in >80% of treatment sessions.
Rehabilitation assessments for the treatment group were completed
within one week of admission to the program. Structured weekly team
case conferences assessed patient progress and goal setting. Adverse
effects of rehabilitation were noted (falls, injury during treatment).
Measurement
The ICF (8) was used as a conceptual basis for choice of best outcomes
for measurement.
BT-related information. This included: socio-demographic data, co-
morbid conditions (diabetes, ischemic heart disease), presence of
dysphasia; and BT lesion size, type, tumour grade and localization;
and treatments received.
Perceived Impact of Problem Profile (PIPP) (28), a 23-item scale
with 5 subscales: Mobility, Self-care, Relationships, Participation and
Psychological Well-being, assessed the impact associated with BT. For
each item, respondents were asked to rate how much impact has your
current health problems had on (item of function or activity), using
a 6-point scale (no impact and extreme impact), with high scores
indicating greater impact.
Statistical analysis
The FIM (motor) was the primary outcome for this study. The study
was powered with 36 patients in each group needed for a 80% chance
to detect a 3-point difference in FIM from baseline to 6 months in
intervention versus control groups, assuming similar standard devia-
tion (SD) change of 8.5 in both groups (two-sided alpha=0.05). The
primary analyses were conducted using analysis of covariance (AN-
COVA), comparing the post-treatment scores (3 and 6 months follow-
up) for the control and treatment groups, with the baseline score as a
covariate. Mann-Whitney U tests compared change scores on each of
the outcome measures (FIM, CARES-SF, DASS and PIPP) (baseline
minus first and second post-treatment follow-up) for the treatment
and control groups. Effect size statistics (r) were calculated and as-
sessed against Cohens criteria (0.1=small, 0.3=medium, 0.5=large
effect) (29). Additional analyses were conducted comparing change
scores on all measures. A p-value of <0.05 was considered statistically
significant. Analyses were on an intention-to-treat (ITT) basis, with
patients assigned according to their initial allocation irrespective of
their subsequent compliance to the protocol.

Measures of impairment. Visual Analogue

Pain scale assessed pain (score range 0 to
10), with higher score indicating greater pain.

Measures of activity. Functional Independence Patient identified from Melbourne

Measure (FIM) (25) assessed the burden of Health database
Excluded; n =710
care. The FIM has 18 categories: motor section n =862
Out of geographical
with 13-items assessed level of function in 4 area=39
subscales: Self-care, Transfers, Locomotion Deceased or record
and Sphincter control; and Cognition with 5 destroyed=651
items. Participants rated each item on a scale Patient eligibility for inclusion in Incomplete or missing
of 1 to 7 (1=total assistance, 2=moderate as- the study and invited to participate information=20
sistance, 3=maximal assistance, 4=minimal n =152
assistance, 5=needs supervision, 6=modified Excluded; n =46
independence, 7=independent). The score Deceased=8
reflects dependency in each area measured. Not contactable or
relocated=23
Measures of participation. Cancer Rehabilita- Declined =15
tion Evaluation System-Short Form (CARES- Patient consented to participate and baseline
SF) (26), a self-administered 59-item measure, assessment conducted
assessed cancer-specific rehabilitation need n =106
and QoL. Global scores indicated QoL with
summary scores for the 5 domains: physical,
psychosocial, medical interaction, marital and
sexual function. The participant rated the de- Allocated to Allocated to
gree to which a given problem applied during Intervention group Allocation Control group
the 4 weeks before the survey. Scoring was n =53 n =53
based on a 4-point Likert scale, with higher
scores indicating more difficulty or impairment.
Assessed n =49 3-month Assessed n =49
Depression Anxiety Stress Scale-21 (DASS)
(Deceased=2, declined=2) (Deceased=2, declined=1,
(27), a 3 7-item self-report scale measured Follow-up not contactable=1)
the negative emotional states of depression,
anxiety and stress. Participants rated the extent
to which they experienced each state over the
past week on a 4-point Likert rating scale. Assessed n =41 Assessed n =44
6-month
Sub-scale scores were derived by totalling (Deceased=6, not (Deceased=2, not
Follow-up contactable=2, declined=1)
the scores, and multiplying by two to ensure contactable=2)
consistent interpretation with the longer DASS
42-item version. Fig. 1. Flow chart of recruitment process.

J Rehabil Med 46
 Effectiveness of multidisciplinary rehabilitation in brain tumour 757

RESULTS Table I. Socio-demographic and clinical characteristics of participants (n=106)

Intervention group Control group
Of the 106 participants, 53 each were allocated Characterisitics (n=53) (n=53)
to the treatment and control groups. Four parti
Demographic factors
cipants in each group dropped out at the 3-month Age, years, mean (SD) [range] 53.1 (13.3) [2177] 49.6 (13.8) [2874]
follow-up assessment (T2) and a further Sex, female, n (%) 31 (58.5) 30 (56.6)
13 dropped out (8 in intervention group and 5 in Marital status, n (%)
control group) at the 6-month assessment (T3) Married/Partner 41 (77.4) 40 (75.5)
Single/Divorced/Separated/Widow 12 (22.6) 13 (24.5)
(Fig. 1). None in the control group required
Living status, n (%)
treatment during the study period. There was Alone 9 (17.0) 9 (17.0)
96% compliance with treatment programme, as Partner/Family 43 (81.1) 44 (83.0)
per the a priori compliance definition. Education, n (%)
Secondary 24 (45.3) 31 (58.5)
Tertiary 24 (45.3) 18 (34.0)
Baseline characteristics Smokers, n (%) 9 (17.0) 8 (15.1)
Participants socio-demographic and clinical Consumes alcohol, n (%) 21 (39.6) 24 (45.3)
characteristics at baseline (T1) are summarized Clinical characteristics
Disease duration, years, median, (IQR) 1.9 (0.83.8) 2.3 (0.85.5)
in Table I. Mean age of the participants was 51 WHO tumour grade (Gliomas)a (n=96), n (%)
years (SD 13.6) (range 2177 years), most were Grade I 10 (20.8) 4 (8.3)
female (56%) and median time since diagnosis Grade II 12 (25.0) 18 (37.5)
was 2.1 years (interquartile range (IQR) 0.9 Grade III 10 (20.8) 5 (10.4)
4.0). Although both groups were well matched Grade IV 16 (33.3) 21 (43.8)
Treatment, n (%)
for demographic and clinical characteristics, Steriods during treatment 36 (67.9) 32 (60.4)
the control group had slightly longer disease Surgery, 2 surgery episodes (n=105) 15 (28.3) 18 (34.6)
duration (median 2.3 years, IQR 0.85.5 vs. Chemotherapy 24 (45.3) 27 (50.9)
1.9 years, IQR 0.83.8 years) and higher grade Radiotherapy 33 (62.3) 35 (66.0)
tumours (21 vs. 16), compared with the treat- Currently on medications (n=99), n (%) 23 (46.0) 17 (34.7)
Co-morbidities (n=65), n (%)
ment group; this however, was not statistically Hypertension 16 (44.4) 14 (48.3)
significant. Participants in both groups had high Diabetes 3 (8.3) 2 (6.9)
levels of functional independence (high Medical Depression 4 (11.1) 3 (10.3)
Research Council scores). Although BT-related Pain/headache, n (%) 31 (58.5) 28 (52.8)
symptoms (and pain/headache) were prevalent Pain score (n=59), median (IQR) 5 (37) 3 (2 5)
Pain scoreb >5, n (%) 10 (32.3) 6 (24.1)
in both groups (Table I), the treatment group Limb weakness (MRC motor scale)c,
reported significantly higher ataxia/incoordina- median (IQR)
tion, dysarthria and visual problems. The mean Left upper limb 4 (45) 4 (45)
duration of the rehabilitation program was 21 Right upper limb 4 (45) 4 (45)
days (range 1432 days). No adverse events Left lower limb 4 (45) 4 (45)
Right lower limb 4 (45) 4 (45)
were reported in either group. There was no Symptoms, n (%)
significant difference between participants lost Ataxia/incoordination* 20 (62.3) 14 (26.4)
to follow-up and those who provided post- Seizures 25 (47.2) 20 (37.7)
treatment results in terms of gender, age, BT Paresis 25 (47.2) 14 (26.4)
duration and median scores for measures used. Cognitive impairment 24 (45.3) 20 (37.7)
Visual impairment* 25 (47.2) 12 (22.6)
Dysphasia (residual expressive) 25 (40.5) 17 (32.1)
Outcome measurements change scores Dysarthria* 18 (28.6) 7 (17.0)
Sensory-perceptual deficit 14 (26.4) 11 (20.8)
Summary data for all outcome measures at Bowel/bladder dysfunction 11 (20.8) 10 (18.9)
different time periods are provided in Table II. QoLd, median, (IQR) 3 (23.5) 3 (24)
QoL score >3, n (%) 13 (24.5) 16 (30.2)
Short-term subjective outcomes. At 3 months *p<0.05.
post-treatment follow-up, Mann-Whitney U a
WHO grading (gliomas): Grade I: slow growing, discrete, often surgical cure e.g., Astrocytic
tests revealed a significant difference between tumours; Grade II: slow growing but ability to invade adjacent normal tissue and higher
treatment and control group participants in all grade of malignancy e.g., Oligodendrogliomas; Grade III: tumours actively reproducing
FIM subscales: self-care, sphincter, loco- abnormal cells that can infiltrate adjacent cells e.g., anaplastic oligodendroglioma; Grade
IV: highly malignant and infiltrating into adjacent tissue e.g., Glioblastoma.
motion, mobility, communication (p<0.01 b
No pain: 0, extreme pain: 10.
for all), with small to moderate effect size (ES) c
No contraction: 0, normal power: 5.
(r=0.3 to 0.4) and FIM psychosocial subscale d
Delighted: 0, terrible: 6.
(p<0.05, r=0.2). There were no significant, IQR: Interquartile range; MRC: Medical Research Council; QoL: quality of life; ROM:
short-term effects on other scores (Table II). range of motion; SD: standard deviation; WHO: World Health Organisation.

J Rehabil Med 46
758 F. Khan et al.

Table II. Summary of intention-to-treat analysis of outcomes of rehabilitation program

Intervention group Control group
T1 (baseline) T2 (3-month) T3 (6-month) T1 (baseline) T2 (3-month) T3 (6-month) Z values Effect size
(n=53) (n=49) (n=41) (n=53) (n=49) (n=44)
Scales Median (IQR) Median (IQR) Median (IQR) Median (IQR) Median (IQR) Median (IQR) T1T2 T1T3 T1T2 T1T3
FIM Motor 67 (61.575.5) 85 (76.588) 79 (67.586) 70 (6578) 78 (7878) 74 (6978) 3.13** 2.33* 0.32 0.25
Self-care 32 (3136) 38 (3041) 36 (3041) 36 (3236) 36 (3636) 34 (3236) 2.67** 1.90 0.27 0.21
Sphincter 11 (1012) 13 (1314) 14 (1314) 12 (1012) 12 (1212) 12 (1112) 4.10** 4.05** 0.41 0.44
Locomotion 10 (611) 12 (1013.5) 11 (912) 10 (1012) 12 (1212) 11.5 (1012) 2.84** 0.89 0.29 0.10
Mobility 15 (1518) 20 (1821) 18 (1520) 15 (1518) 18 (1818) 18 (1518) 3.01** 1.91 0.30 0.21
FIM cognition 25 (2328.5) 31 (2733) 31 (27.533) 27 (23.529) 30 (2930) 28.5 (2630) 1.99* 3.09** 0.20 0.34
Communication 10 (1012) 13 (1214) 13 (11.514) 12 (1012) 12 (1212) 12 (10.312) 2.60** 4.86** 0.26 0.53
Psychosocial 5 (56) 6 (67) 6 (5.57) 5 (56) 6 (66) 6 (56) 2.05* 3.53** 0.21 0.38
Cognition 10 (811) 12 (813) 12 (1013) 10 (911) 12 (1112) 11 (1012) 0.09 2.51** 0.01 0.27
DASS
Total 20 (630) 12 (227) 8 (124) 16 (423) 4 (111) 6 (221.5) 0.53 0.98 0.05 0.11
Depression 8 (214) 4 (012) 2 (012) 6 (011) 2 (04) 3 (09.5) 0.33 1.9 0.03 0.21
Anxiety 4 (07) 0 (04) 0 (04) 2 (06) 0 (02) 0 (02) 0.76 0.23 0.08 0.02
Stress 6 (2,14) 6 (09) 4 (011) 6 (015) 2 (08) 2 (08) 0.46 0.19 0.05 0.02
PIPP
Total 63 (4880.5) 57 (4776) 58 (39.591) 45 (3559.5) 38 (3351) 35.5 (28.358) 0.40 0.37 0.04 0.04
Psychological 3.6 (2.74.8) 3.3 (2.54.4) 3.8 (2.44.6) 3 (2.14.6) 2.4 (1.63.2) 2.2 (1.42.9) 0.67 0.98 0.07 0.11
Self-care 1.5 (12.5) 1.3 (12) 1 (12.9) 1 (11.4) 1 (11.3) 1 (11.3) 1.03 0.44 0.10 0.05
Mobility 2.8 (23.5) 2.6 (23.6) 2.4 (1.64.2) 1.8 (12.6) 1.6 (12.2) 1.7 (12.4) 1.11 0.86 0.11 0.09
Participation 3.4 (2.34.5) 3.6 (2.24.4) 3.4 (24.8) 2 (1.43.7) 2 (1.22.6) 1.8 (13.2) 0.04 0.04 0.00 0.00
Relationship 1.3 (12.3) 1.5 (12.4) 1.5 (13.3) 1.3 (11.8) 1 (11.5) 1 (12.1) 0.36 1.13 0.04 0.12
CARES-SF (global)
Physical 1.3 (0.81.8) 1 (0.51.6) 1 (0.41.9) 0.7 (0.31.1) 0.3 (00.6) 0.3 (0.11.2) 0.18 0.13 0.02 0.01
Psychological 0.7 (0.41.3) 0.6 (0.31) 0.4 (0.11.1) 0.5 (0.31.1) 0.2 (0.10.6) 0.3 (0.10.7) 1.02 0.49 0.10 0.05
Medical 0 (00.5) 0 (00.3) 0 (00.6) 0 (00.5) 0 (00) 0 (00) 1.07 0.93 0.11 0.10
Marital 0.2 (00.8) 0.2 (00.8) 0 (00.8) 0.2 (00.4) 0 (00.2) 0 (00.2) 1.08 0.09 0.11 0.01
Sexual 0.3 (01.6) 0.7 (02.9) 2 (02.8) 0.3 (01.3) 0 (01.3) 0.4 (01.3) 0.66 1.40 0.07 0.15
Overall 0.8 (0.51.2) 0.7 (0.41.1) 0.6 (0.31.3) 0.5 (0.30.8) 0.3 (0.10.5) 0.3 (0.10.7) 0.10 0.42 0.01 0.05
*p<0.05-value (2-tailed); **p<0.01-value (2-tailed).
CARES-SF: Cancer Rehabilitation and Evaluation System short form; DAS: Depression Anxiety Stress Scale; FIM: Functional Independent Measure;
PIPP: Perceived Impact of Problem Profile; SD: standard deviation; IQR: interquartile range.

Longer-term subjective outcomes. At 6 months follow-up,
compared to the control group, statistically significant im-
provement in the treatment group was maintained for the FIM
sphincter (p<0.01, r=0.4) and communication (p<0.01,
r=0.5) subscales; and psychosocial and cognition (p<0.01
for both), compared to control group. No difference between
groups was noted in other subscales (Table II).
DISCUSSION
To our knowledge this is the first clinical trial evaluating efficacy
of an ambulatory MDR program for BT population (gliomas)
following definitive treatment in an Australian community
cohort. The participants were with established impairments
and functional disability, with median time since diagnosis
of 2 years. These results provide some support for MDR for
functional gain and psychosocial adjustment after BT treatment,
consistent with other reports (6, 1316, 18, 30, 31). The treat-
ment group compared with the control group, showed improved
activity at 3 months following MDR and psychosocial gains
were maintained at 6-month follow-up. There were no changes
in other outcome measures (DASS, PIPP and CARES-SF Global
scores) at both time-points. The participants in this study were
similar to those in other studies with respect to demographic
and clinical characteristics (1315, 18, 32). The rehabilitation
program provided standard treatment and management in ac-
cordance with existing BT care guidelines (33, 34).
It is not surprising that targeted MDR in BT survivors im-
proved activity (self-care, mobility, continence) in the shorter-
term (3 months) as they benefit from intensive reconditioning,
exercise and task re-acquisition strategies. Many also showed
improvement in psychosocial interactions, communication
and cognitive abilities (problem solving, memory), with gains
maintained at 6 months follow-up. This may be due to cessation
of radio/chemotherapy regimens for those with more aggres-
sive tumour types and improved fitness through structured
and specific interventions within the MDR program. Partici-
pants in this study were complex in terms of disease severity,
symptoms and co-morbidities (reflective of clinical practice)
and presented with a range of survivorship issues, which
required an individualized approach. Standardizing therapy
was difficult, therefore individualization of treatments was
used (i.e., a described intervention provided by therapist X,
e.g., a 30-min treatment session included a stretching and
muscle strengthening protocol) (35). However, determining
the effective dose, intensity, components and combination of

J Rehabil Med 46
 Effectiveness of multidisciplinary rehabilitation in brain tumour
treatment modalities in rehabilitation in the study population
was not possible, and further research is needed.
With improved BT survival rates there is a growing acceptance
of the longer-term factors impacting psychological functioning
and QoL, however, these are often under-estimated (36, 37).
Participants in this study did not show improvement in outcome
measures assessing participation and QoL. This is not surpris-
ing as QoL is a difficult concept to measure, as many factors
influence it. Survivorship issues (pain/headache, fatigue, low
mood, psychosocial needs, the physical effects of treatment and
consequences) can influence coping with cancer, attainment of
previous levels of functioning (36), and negatively influence
QoL (37). The optimum assessment tools for participation in BT
are yet to be identified, and vary in different studies. Measures
such as CARES-SF, PIPP, DASS have ceiling effects, although
they show clinical change with treatment but low statistical
significance (ES). These issues have important implications for
longer-term monitoring, education, health promotion, support
and counselling of the BT patients (and their families) (22).
Rehabilitation in BT survivors is challenging as they can
present with various combinations of disabilities (physical,
cognitive, psychosocial, behavioural and environmental) (3,
9). The ICF (8) provides a useful framework for describing
the impact of disease at the level of limitation in activity and
participation. Our initial study (n=106) (23) highlighted the
patient-perspective of functional limitations due to BT, using
the ICF domains and linkage with ICF categories for relevant
issues following definitive treatment. Participants identified
many relevant ICF categories (88%), indicating a range of
potential problems in: mobility, domestic life, inter-personal,
family and intimate relations, and major life areas (economic
self-sufficiency, remunerative employment). The most fre-
quent issues identified (driving, recreation, and remunerative
employment), reflected the socio-demographic characteristics
and age distribution of participants (working age, educated,
living with family) (23). Further, at 2 years following definitive
treatment, these BT participants (n=106) (11) showed that,
despite good functional recovery over one-half reported pain
(mainly headache), followed by impairments such as ataxia
(44%), seizures (43%); paresis (37%), cognitive dysfunction
(36%) and visual impairment (35%). This study also found that
about 20% reported high levels of depression compared with
only 13% in an Australian normative sample (11). Emphasis
should be on a longer-term monitoring of maintenance of func-
tion and psychological sequelae in the community.
There were many challenges in conducting a clinical trial in
a rehabilitation setting, similar to other reports (38, 39). This
study has some potential limitations. First, randomisation of
the participants was not possible due to ethical considerations;
methodological issues included heterogeneous patient charac-
teristics, multilayered treatments, interdependent components
and individual interventions. Second, selection bias cannot be
ruled out as participants are a selective cohort listed on a single
database held at single tertiary institution (RMH) who agreed to
participate in research projects. This may limit generalizability
of findings. However, all eligible participants on the database
759
were contacted, irrespective of their demographic or disease
status, and the study cohort covered a wide geographical popula-
tion in Victoria representing a wider sample of BT survivors in
the community. Comparison and generalisability of these results
is difficult, larger sample sizes in different settings are needed
to confirm these findings. There was no statistical difference in
any of the study variables between participants who completed
post-treatment assessment and those lost to follow-up. We
acknowledge that other factors may have impacted depression
and QoL in BT participants and were not studied. More research
into ongoing pain and other outcomes is needed. To reduce po-
tential bias the treating therapists and assessors were blinded.
The assessors were independent of the rehabilitation or acute
hospital teams. Important outcomes such as impact on carers and
families and analysis of costs associated with care were beyond
the scope of this study. The impact of other different components
of MD rehabilitation modalities and interventions is unknown.
This study highlighted challenges associated with conducting
research in the real world setting of a tertiary public hospital
with finite resources. It was difficult to recruit participants as
many were still undergoing radio/chemotherapy post-surgery,
the mortality rates for aggressive BTs was high, and transport
was an issue for those residing further away from our facility.
There were no patient referral protocols for treating medical/
surgical staff for an integrated neuro-rehabilitative-palliative
approach (40). This required education of various treating teams
and integration of existing services that operated in silos, with
fragmented service delivery. The control group were informed
of the wait time for rehabilitation services as per usual practice,
and were not unduly disadvantaged. Operationally, it was beyond
the resources of our hospital to provide therapy for this many
patients simultaneously. Rehabilitation is an expensive interven-
tion. The implications of this study include triaging and prior-
itizing the BT survivor who needs targeted rehabilitation input.
Rehabilitation for BT survivors is challenging due to high
mortality rates. The condition is often progressive in nature,
with an uncertain prognosis, and multifaceted physical, psycho-
logical and cognitive disabilities, and participatory limitations
that require an integrated interdisciplinary approach (4). This
study provides some evidence to support MDR for improved
activity in BT survivors in the shorter-term. More research in
the effectiveness of specific rehabilitation interventions and
participation domains is needed. The MDR for BT survivors
should be considered by treating clinical teams to improve dis-
ability management. Further, emphasis on outcome-orientated
research to explore service models and strategies to implement
individualized treatment and integrated MDR programs is
needed to address survivorship issues in BT.
ACKNOWLEDGEMENT
We are grateful to all participants with primary brain tumour in this study.
We thank Ms L Oscari, Dr K Mackenzie and Dr I Rajapaksa for patient
assessments; Dr L Ng for assistance with ethics submission and T Khan
for data entry.
The authors declare no conflicts of interest.
J Rehabil Med 46
760 F. Khan et al.
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